Failure to Monitor Antipsychotic Medication Effects: The facility failed to monitor a resident for adverse effects related to antipsychotic use. A cognitively intact resident was receiving Rexulti for dementia-related diagnoses, but the MAR had no monitoring orders and the CCP had no plan for antipsychotic monitoring. The DON confirmed the required monitoring was not completed as required by facility policy.
The facility failed to identify and monitor resident-specific target behaviors for two residents receiving psychotropic meds, failed to monitor for EPS/tardive dyskinesia with antipsychotic use, and used an inappropriate diagnosis for risperidone in one resident. One resident had intact cognition with depression, anxiety, hemiplegia, and seizure disorder, while the other had moderate cognitive impairment with dementia and depression; records and the DON confirmed that the CCP, orders, MAR, and EMR did not include resident-specific behavior monitoring or EPS assessments.
Missing End Date for PRN Psychotropic Medication: A resident with COPD, DM2, schizophrenia, bipolar disorder, depression, and anxiety had a PRN clonazepam order for anxiety with no end date. The pharmacist noted PRN psychotropic meds should have a stop date unless the provider documents a clinical rationale and new duration, and the ADON confirmed the MAR/record lacked an end date.
Psychotropic medication monitoring deficiencies were identified for multiple residents. One resident with bipolar disorder, MDD with psychotic symptoms, and GAD received Seroquel and sertraline, but the EMR, MAR, and TAR did not show specific target behaviors or side effect monitoring despite behavioral concerns being listed in the care plan. Another resident with schizoaffective disorder, bipolar type, received multiple psychotropic medications, but no target behaviors were documented, and the DON confirmed this. The report also noted missing AIMS testing for one resident and lack of sleep pattern monitoring for hypnotic use in three residents.
A resident with dementia, Parkinson’s disease, depression, and a history of myocardial infarction had a PRN order for Zyprexa 5 mg every 6 hours for agitation related to dementia that lacked a 14-day limit or specified duration, as required by facility policy. Record review showed no practitioner documentation of review or renewal of this PRN antipsychotic order, and the DON and interim DON confirmed the absence of an end date and physician notes addressing continuation of the medication.
Failure to Monitor Psychotropic Medication Side Effects: The facility did not document side effect monitoring for three residents receiving psychotropic meds. One resident with dementia and anxiety received lorazepam and mirtazapine, another with anxiety, panic disorder, OCD, and schizophrenia received fluvoxamine, and a third with delusional disorder, mood disorder, dementia, anxiety, and OCD received quetiapine. Although care plans directed staff to observe for side effects and report adverse reactions, the MAR/TAR and chart lacked documentation, and the Administrator and an LPN confirmed the monitoring was not being done.
A resident with dementia, anxiety, depression, and impaired cognition was started on Seroquel 25 mg nightly after episodes of refusal and aggression. The EMR had no evidence of a baseline AIMS before the antipsychotic was initiated, and the consultant pharmacist twice recommended AIMS monitoring for potential movement-disorder side effects before the assessment was finally completed months later.
Inadequate indication and clinical rationale for olanzapine use: The facility administered olanzapine to two residents without documented clinical rationale consistent with policy and accepted indications. One resident received the antipsychotic for anxiety despite the DON confirming that anxiety was not an approved use and no rationale was documented. Another resident with dementia-related behavioral disturbance received olanzapine for yelling and agitation, with records showing dose changes, a GDR request, and notification to the resident’s representative about behavioral use.
The facility failed to document a provider clinical rationale and duration for continuing PRN psychotropic medication beyond 14 days for two residents. One resident had PRN lorazepam for anxiety with no end date or documented rationale, and another resident with TBI, anxiety, MDD, and cognitive impairment had PRN lorazepam continued without documentation explaining the extension. The DON could not initially produce the required rationale, and later documentation only noted the medication was for anxiety and to add a stop date in 14 days.
A facility failed to identify and monitor specific target behaviors for antipsychotic use for two residents. One resident had severe cognitive impairment and was receiving Quetiapine and Rexulti for anxiety/agitation, while another resident with intact cognition and schizophrenia was receiving Rexulti for agitation. In both cases, the chart contained side effect monitoring orders, but no resident-specific target behaviors were documented in the care plan, physician orders, or EMR, and the DON confirmed the gap.
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